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Association of Low Back Pain with Common Risk Factors: A Community Based
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DOI: 10.5005/ijopmr-25-2-50

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50

Original Article
Association of Low Back Pain with Common Risk Factors:
A Community Based Study
Aminuddin A Khan1, Mohammad Moin Uddin2,
Ahsanul Hoque Chowdhury3, Ranjan Kumar Guha4

Abstract
Background: Low back pain is very common in Asian communities. It is a major cause of activity limitation. Its risk
factors were not studied well in Asian communities. This study was performed in the rural area to see the association of
some common posture related and modifiable risk factors of low back pain.
Methods: This is a community based case-control study. Participants of both sexes between 30 and 60 years were
selected who had low back pain. Data were collected with a semi-structured questionnaire and fifty-one participants
were interviewed from which 32 had back pain (cases). Risk factor association was compared with age and ethnicity
matched 19 patients without low back pain (control group).
Results: The point prevalence of low backache was 63%. Mean age of the patients was 45.8 (±10.8 SD) years. Seventy
per cent of the back pain patients were females and 30% were males. Back pain was significantly associated with the risk
factor 'bending and twisting movements of the body' (OR= 4.6 with 95% CI= 1.1 to 18.9, p= 0.041). It was not found to
be significantly associated with the other studied risk factors.
Conclusion: Low back pain had a very high prevalence in rural Bangladesh. Bending and twisting movements of spine
was the only posture related significant risk factor of low back pain.

Key words: Bangladesh, case-control, low back pain, prevalence, risk factors.

Introduction: of as a problem confined to Western countries5; however,

L ow back pain (LAP) is an extremely common health
problem1-4. Until 10 years ago, it was largely thought
Author's affiliations:
1 MBBS, FCPS (PM&R), Professor & Head
2 MBBS, CCD (Diabetes), FCPS resident trainee (PM&R),
3 MBBS, FCPS Trainee (PM&R), Medical Officer
4 Bsc (Honours), Msc., Joint Director
Department of Physical Medicine & Rehabilitation, Chittagunj
Medical College, Bangladesh.
Cite as:
Aminuddin A Khan, Mohammad Moin Uddin, Ahsanul Hoque
Chowdhury, Ranjan Kumar Guha. Association of low back pain with
common risk factors: a community based study. IJPMR June 2014;
Vol 25 (2): 50-5.
Correspondence:
Dr. Aminuddin A Khan, Professor & Head,
Chittagunj Medical College, Bangladesh
Received on 25/07/2013, Revised on 24/01/2014,
Accepted on 19/03/2014
since that time an increasing amount of research has
demonstrated that low back pain is also a major problem
in low- and middle income countries6-9. Low back pain
is the leading cause of activity limitation and work
absence throughout much of the world10, and it causes a
great economic burden on individuals, communities and
governments11-13.
The point prevalence of LBP is 28.5% found in an Asian
country14. The lifetime prevalence of low back pain is
reported to be over 70%15. But globally, the annual
prevalence of LBP has been estimated at 38%. In general,
LBP resolves within weeks, but may recur in 24-50% of
cases within 1 year. Thus, the identification of risk factors
for LBP is important in the prevention of recurrent and
possibly chronic LBP16. The prevalence of LBP in
children is low (1%-6%)17 but increases rapidly (18%-
50%) in the adolescent population18,19. The prevalence
of LBP peaks around the end of the sixth decade of life20.
The age distribution of LBP is unimodal, with the peak
prevalence occurring in those aged 45 to 59 years old.
This is also similar to USA epidemiological data

50
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Association of Low Back Pain with Common Risk Factors – Aminuddin A Khan et al
describing the peak point prevalence, period prevalence
and lifetime prevalence all within ages 55 to 64 years21.
Low back pain is pain, muscle tension, or stiffness,
localised below the costal margin and above the inferior
gluteal folds, with or without referred or radicular leg
pain (sciatica)22. Low back pain is typically classified
as ‘specific’ and ‘non-specific’. Specific LBP is caused
by specific pathophysiological mechanism whereas non-
specific LBP is defined as symptoms due to non-specific
cause, i.e. LBP of unknown origin. LBP is defined as
acute when persists less than 6 weeks, subacute between
6 weeks and three months and chronic when lasts longer
than 3 months. Approximately 90% of all LBP patients
have non-specific causes23.
The most important symptoms of LBP are pain and
disability (activity limitation). Recently it has been
suggested that a substantial proportion of patients with
chronic LBP have widespread pain24,25.
Different anatomical structures and pathophysiological
functions can be responsible for lumbar pain, each
producing a distinctive clinical profile. Pain can arise
from the intervertebral disc in which case, greatest pain
provocation will be associated with movements and
functions in the sagittal plane. Lumbar pain can also arise
from afflictions within the zygapophyseal joint
mechanism, which will produce the greatest pain
provocation during three-dimensional movements, due
to maximal stress to either the synovium or joint
cartilage. Finally, patients can experience pain associated
with irritation to the dural sleeve, dorsal root ganglion,
or chemically irritated lumbar nerve root. Pain can also
arise from muscle26.
More than 100 risk factors for LBP have been
identified27. In the majority of cases, a combination of
individual and work-related as well as non-work-related
factors is likely to contribute to the development of
LBP28. A wide range of work-related mechanical risk
factors for LBP have therefore been reported in
prospective studies. They include ‘bending or
twisting’ 29,30, ‘kneeling or squatting’ 31, ‘prolonged
standing’32, ‘heavy physical work’33,34, and ‘nursing
tasks’ (e.g., manually moving patients)35,36. Overall,
however, the evidence showing works postures, manual
handling and carrying to be risk factors for LBP remains
inconclusive37.
In recent decades, there has been increased emphasis on
work-related psychosocial factors in epidemiological
studies of LBP. There is some evidence that
psychological demands 38,39, and high job strain40 are
September Issue-2012 (3rd Proof)
51
related to LBP. Lack of social support has been
demonstrated to increase the risk of sick leave associated
with LBP 41. However, the level of evidence for most
psychosocial factors is limited 42,43 . Smoking
behavior44,45, Life style, lack of physical exercise46 and
short sleep hours47 are also found to increase the risk of
LBP
Aging is a well known risk factor of LBP as degenerative
changes in the spine and disc are one of the major causes
of LBP48. Previous studies reported the association
between age and LBP among Asian population49 as well
as the western population46,50. The association between
gender and LBP had been reported by previous
studies44,45. A systematic review showed that there was
no evident relationship between alcohol consumption
and LBP 51.
Low back pain is one of the major causes of activity
limitation and work absence throughout much of the
world10. It is the second most common reason for visits
to physicians52. The point prevalence of LBP is 28.5%
found in an Asian country14. Seventy per cent people
have the chance of developing LBP at least once in life15.
The economic burden of this disease is enormous.
Although data from Asian countries are not available,
the Quebec Workers Compensation System showed that
the LBP was responsible for 73% of the medical costs,
and 76% of the compensation costs53. In UK its treatment
cost is 500 million pounds a year at the GP level54. So it
is important to chalk out the risk factors for LBP in order
to take preventive measures and to reduce the posture
related modifiable risk factors among the rural people
of our country.
Materials and Methods:
Study design and settings
It is a community based case-control study done at
‘Bangladesh Academy for Rural Development’ (BARD),
Kotbari, Comilla, Bangladesh. Data were collected from
Raichaw village of Comilla and analyzed at BARD.
Participants and procedure
Participants were selected from the inhabitants of
Raichow village by non-probability sampling. Both male
and female participants were chosen whose age between
30 and 60 years. Total 51 participants, irrespective of
their gender, were interviewed consecutively. Severely
ill patients (e.g., stroke, MI, paraplegic patients),
pregnant women, patients with history of inflammatory
back pain (morning stiffness >30 minutes), patients with
‘red flag’ symptoms were exempted from the purview
52 IJPMR 2014 June; 25(2): 50-5

of the study. People unwilling to give interview were Results:

also excluded. Patients who had back pain previously,
Among 51 participants, 32(63%) had LBP and 19 (37%)
but not at the time of interview, were not included.
did not. The point prevalence of LBP was 63% . Mean
Participants within the specified age group who had the age of the 32 LBP patients was 45.8 (±10.8 SD) years;
complaints of LBP at the time of data collection were median age was 48 years (Fig 1). Seventy per cent of the
defined as ‘LBP’ group (case). Age and ethnicity (people LBP patients were females and 30% were males (Fig 2).
of same village) matched patients with no LBP were Regarding occupation, around 70% were housewives,
allocated as ‘no LBP’ group (control). Total 32 patients 18% were farmers, 6% were businessmen and the rest
were included as cases and 19 patients as controls. 6% were unemployed (Fig 3).
Data collection Around 94% of all the back pain patients were married,
A semi-structured questionnaire was used to interview 3% were single and 3% had other marital status. Mean
and collect data. The questionnaire included three open duration of LBP was found 3.5 (±2.5 SD) weeks among
ended and eight closed ended questions. People were the villagers. Median duration was 3 weeks (Fig 4). Sixty
interviewed and questionnaires were filled up by the seven per cent of the LBP patients consulted with
interviewers. The interviewers went from home to home physicians and 82% of them had the knowledge that body
and talked to the people within 30 to 60 years. movements are related to development of LBP.
Statistical analysis
Data were edited, checked and verified manually. Data
were analysed and presented by the help of SPSS-V15.
Association of risk factors with LBP was seen by odds
ratio (95% CI), Chi-square test and likelihood ratio.
Strength of association was examined by Phi & Cramer’s
V test. P value <0.05 was used to see level of significance.
LBP and risk factors
Low back pain (LBP) is pain, muscle tension, or stiffness,
localized below the costal margin and above the inferior
gluteal folds, with or without referred or radicular leg
pain (sciatica)22. Demography means the study of the
characteristics of human populations, such as size,
growth, density, distribution, and vital statistics. Here
we used age, gender, occupation, religion and marital
status55. Activities related to different body postures like
‘bending and twisting movements of spine’ 29,30 ,
‘kneeling and squatting movements of the body’31,
‘prolonged standing’32, ‘and heavy physical works’33,34
were assessed in this study. Fig 1- Histogram Showing Mean Age of LBP Patients and
For ‘bending and twisting movements’ participants were Frequency Distributions
asked, ‘Do you work in positions where you are leaning
forward without supporting yourself on your hands or
arms?’ For ‘kneeling and squatting’ they were asked, ‘Do
you need to squat or kneel in the course of your work?’
And for standing, ‘Do you work standing up?’ (Response
categories: yes/no). Heavy lifting was measured with a
single item: ‘Do you have to lift anything that weighs
more than 20 kg on a daily basis? 16 Some other
modifiable risk factors like ‘smoking’44,45 at present or
in the past, ‘history of trauma to the back’46 within 4
weeks prior to back pain and ‘sleeping less than 6 hours’
in 24 hours47 were also studied. Fig 2- Pie Diagram Depicts Gender Variations in LBP

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Association of Low Back Pain with Common Risk Factors – Aminuddin A Khan et al
LBP was associated with the only posture related risk
factor- ‘bending and twisting movements of the body’
(odd’s ratio 4.6 with 95% CI=1.1 to 18.9), There was
statistically significant association of LBP with bending
and twisting movements (p=0.041). Likelihood ratio also
significant (p=0.04). Good strength of association
(p=0.041) between LBP and bending and twisting
movements. LBP was not found to be significantly
associated with the other risk factors kneeling and
squatting (OR=1.18, 95% CI=0.38-3.67, p=0.30),
prolong standing (OR=3, CI= 0.57-15.7; p=0.14), heavy
Fig 3- Bar Diagram Showing Different Occupation of LBP
Patients
Fig 4- Histogram Demonstrates Frequency Distribution of
Back Pain Duration
September Issue-2012 (3rd Proof)
53
working (OR=2.26, CI=0.6-8.4; p=0.15), back trauma
(OR=1.6, CI=0.36-6.4; p=0.84), smoking (OR=0.94,
CI=0.23-3.7; p=0.57), sleeping <6 hours/day (OR=1.7,
CI=0.46-6.5; p=0.83) (Table 1).
Discussion:
This study was undertaken to see the demographic
patterns of LBP in rural Bangladesh and to look into its
association with some common risk factors in the
perspective of Bangladeshi villagers. We found the point
prevalence of LBP is much higher (63% than
contemporary studies for example 29% (Tomita et al14.)
but Kent et al12. showed point prevalence may vary
widely from one region to another which might be due
to variation in sample and sampling technique.
Mean age of LBP patients was 45.8 (±10.8 SD) which is
a bit lower than the value (peak age 45 to 59 years) shown
by Kent et al12. Like previous other studies44,45 where
female were found to suffer more from LBP, we found
similar results (70% females) although more female
predominance is due might be to more female
participants in our study. Another contributing factor for
female vulnerability is their occupation (housewife)
which involved ‘bending and twisting’ movements of
the spine. 70% of our participants and all female
participants were housewives.
Association between LBP and none of the risk factors
were statistically significant except ‘bending and twisting
movement’ of the spine which is supported by Tomita et
al14. in their study on Thai population. But he showed in
his study a significant association with LBP and history
of back injury, smoking. Duration was not associated
with LBP in that study14.
Squatting/kneeling, prolonged standing, heavy lifting
was also significant in the study at Thiland14 which is
not consistent with ours. Most of our participants were
young and smoking history for short time. This may be
a possible explanation of lack of association because
Miranda et al46 showed association of LBP with smoking
in only over 50 years population.
Conclusion:
Association between LBP and ‘bending and twisting
movement’ was statistically significant .The study
revealed a high prevalence of back pain in rural area.
Females were considerably more sufferers from back
pain. Backache was found more predominant in middle
and older age group. Multi-centered study in future on
54 IJPMR 2014 June; 25(2): 50-5

Table 1: Showings Association of Different Risk Factors with LBP

Risk factors OR & CI X2 value Likelihood ratio Phi & Cramer’s Remarks
& p-value & p-value V test (P-value)
1) Bending and 4.6 4.1 (df=1) 4.06 (df=1) P= 0.041 Statistically
twisting CI= 1.1–18.9 P= 0.041 P= 0.044 significant
association
2) Kneeling and 1.18 1.04 (df=1) 1.03 (df=1) P= 0.3 No significant
squatting CI= 0.38-3.67 P= 0.3 P= 0.31 association
3) Prolong 3 2.18 (df=1) 2.37 (df=1) P= 0.14 Do
standing CI= 0.57-15.7 P= 0.14 P= 0.12
4) Heavy 2.26 2.05 (df=1) 2 (df=1) P= 0.15 Do
working CI= 0.6-8.4 P= 0.15 P= 0.15
5) Back 1.6 0.04 (df=1) 0.04 (df=1) P= 0.84 Do
trauma CI= 0.36-6.4 P= 0.84 P= 0.84
6) Smoking 0.94 0.31 (df=1) 0.32 (df=1) P= 0.57 Do
CI= 0.23-3.7 P= 0.57 P= 0.57
7) Sleeping 1.7 0.04 (df=1) 0.42 (df=1) P= 0.83 Do
<6 hours/day CI= 0.46-6.5 P= 0.83 P=0.83

larger population might be required in future to explain
the findings.
Conflict of interest:
I declare no conflict of interest with anybody.
Acknowledgement:
I would like to express my heartily gratitude to
Bangladesh Academy for Rural Development (BARD),
Comilla authority for patronising us to undertake the
study. My thanks go to all the hospitable villagers who
received us warmly during data collection. Lastly, thanks
to all training instructors of BARD and my dear
colleagues.
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